Kidney transplant ureteroneocystostomy: comparison of full-thickness vs. Lich-Gregoir techniques

Pearls and Pitfalls in Pediatric Kidney Transplantation After 5 Decades

Worldwide, over 1,300 pediatric kidney transplantations are performed every year. Since the first transplantation in 1959, healthcare has evolved dramatically. Pre-emptive transplantations with grafts from living donors have become more common. Despite a subsequent improvement in graft survival, there are still challenges to face. This study attempts to summarize how our understanding of pediatric kidney transplantation has developed and improved since its beginnings, whilst also highlighting those areas where future research should concentrate in order to help resolve as yet unanswered questions. Existing literature was compared to our own data of 411 single-center pediatric kidney transplantations between 1968 and 2020, in order to find discrepancies and allow identification of future challenges. Important issues for future care are innovations in immunosuppressive medication, improving medication adherence, careful donor selection with regard to characteristics of both donor and recipient, improvement of surgical techniques and increased attention for lower urinary tract dysfunction and voiding behavior in all patients.

Results of a previously unreported extravesical ureteroneocystostomy technique without ureteral stenting in 500 consecutive kidney transplant recipients

Urologic complications can still occur following kidney transplantation, sometimes requiring multiple radiological and/or surgical procedures to fully correct the problem. Previously proposed extravesical ureteral reimplantation techniques still carry non-negligible risks of the patient developing urologic complications. About 10 years ago, a new set of modifications to the Lich-Gregoir technique was developed at our center, with the goal of further minimizing the occurrence of urologic complications, and without the need for initial ureteral stent placement. It was believed that an improvement in the surgical technique to minimize the risk of developing urologic complications was possible without the need for stent placement at the time of transplant. In this report, we describe the advantages of this technique (i.e., mobilized bladder, longer spatulation of the ureter, inclusion of bladder mucosa with detrusor muscle layer in the ureteral anastomosis, and use of a right angle clamp in the ureteral orifice to ensure that it does not become stenosed). We also retrospectively report our experience in using this technique among 500 consecutive (prospectively followed) kidney transplant recipients transplanted at our center since 2014. During the first 12mo post-transplant, only 1.4%(7/500) of patients developed a urologic complication; additionally, only 1.0%(5/500) required surgical repair of their original ureteroneocystostomy. Five patients(1.0%) developed a urinary leak, with 3/5 having distal ureteral necrosis, and 1/5 subsequently developing a ureteral stricture. Two other patients developed ureteral stenosis, one due to stricture and one due to ureteral stones. These overall results are excellent when compared with other reports in the literature, especially those in which routine stenting was performed. In summary, we believe that the advantages in using this modified extravesical ureteroneocystostomy technique clearly help in lowering the early post-transplant risk of developing urologic complications. Importantly, these results were achieved without the need for ureteral stent placement at the time of transplant.

The Ureter in the Kidney Transplant Setting: Ureteroneocystostomy Surgical Options, Double-J Stent Considerations and Management of Related Complications

Purpose of Review

In the setting of kidney transplantation, the ureter is a common source for complications. As a result, prevention of ureteral complications and their management is of crucial importance. In this context, the purpose of this review is to summarize recent literature on the ureter in the kidney transplant setting with a special focus on new findings. We conducted a PubMed and Medline search over the last 10 years to identify all new publications related to ureteroneoimplantations, stents and management of complications in the kidney transplant setting.

Recent Findings

Performance of the “Lich-Gregoir” technique for ureteroneocystostomy seems to be favourable in regard to postoperative complications when compared with other methods described in the literature. Moreover, major urologic complications can be further reduced by ureteral stenting.

Summary

A new approach for management of ureteral strictures in renal transplants is presented. We discussed the usage of a ureteral stent covered with a biostable polymer aiming to prevent tissue ingrowth into the lumen as a new option for management of ureteral stricture in the kidney transplant setting.

Urologic complications in renal transplants

Urologic complications of renal transplant occur commonly and can have significant impact on graft function, survival, and patient morbidity. This review examines the prevalence of urologic complications, risk factors, diagnosis and options for management of the most common urologic complications.

A survey of Canadian renal transplant surgeons: Use of ureteric stents and technique of the ureteroneocystotomy

INTRODUCTION

The role of ureteric stenting in renal transplant has been well-demonstrated. The goal of this survey was to determine the utilization of ureteric stents by Canadian transplant surgeons, and how the ureteroneocystotomy and followup is performed.

METHODS

An online survey was sent to the 40 surgeon members of the Canadian Society of Transplantation. The primary outcome was the rate of ureteric stent use at the time of renal transplantation. The secondary outcomes were the ureteric stent dwell time, use and type of prophylactic antibiotics, and the use of routine post-transplant ultrasonography.

RESULTS

All respondents (25) used ureteric stent routinely and 92% remove the stent between four and six weeks postoperatively. Prophylactic antibiotics were used 64% of the time for ureteric stent removal. The majority of surgeons do not routinely perform a post-stent removal ultrasound. Fifty-six percent of respondents perform a refluxing anastomosis.

CONCLUSIONS

Ureteric stents are routinely used in renal transplant in Canada. Areas for improvement and topics of debate identified from this survey are the need for peri-stent removal antibiotics, the role of post-stent removal ultrasound, the duration of stent dwell time, and the need for a non-refluxing ureteroneocystotomy.

Comparison of Urologic Complications Between Ureteroneocystostomy and Ureteroureterostomy in Renal Transplant: A Meta-Analysis

OBJECTIVES

Transplant surgeons use a myriad of ureteral anastomotic techniques in renal transplant. Although the Lich-Gregoir extravesical anastomosis is the most common, ureteroureterostomy also is used. In this meta-analysis, our objective was to compare the complication rates of these 2 techniques as reported in the literature.

MATERIALS AND METHODS

A systematic review of the literature revealed 44 articles, 6 of which met our inclusion criteria. Studies were compiled using Review Manager (RevMan version 5.3, Nordic Cochrane Centre, Cochrane Collaboration, Copenhagen, Denmark). Forest plots were generated to assess relative risk. A fixed-effects model was used for low heterogeneity, and a random-effects model was used for high heterogeneity.

RESULTS

Overall complications were similar for both procedures (relative risk, 1.22; 95% confidence interval, 0.9-1.65), as were rates of urine leak and fistula (relative risk, 0.79; 95% confidence interval, 0.17-3.64) and hematuria (relative risk, 0.24; 95% confidence interval, 0.001-4.84). Stricture, obstruction, and stone formation were more common after ureteroureterostomy (relative risk, 0.63; 95% confidence interval, 0.45-0.88), whereas vesicoureteral reflux (relative risk, 6.82; 95% confidence interval, 1.68-27.61) and urinary tract infection (relative risk, 2.29; 95% confidence interval, 1.3-4.03) were more common after ureteroneocystostomy.

CONCLUSIONS

With similar overall complication rates, both procedures can be viewed as being acceptable primary anastomotic techniques. In light of differing individual complication rates and the scarcity of data comparing the 2 methods, no specific recommendation regarding that technique should be used can currently be elucidated. We believe that further prospective studies comparing ureteroneocystostomy and primary ureteroureterostomy may reveal which is superior regarding complication rates.

Ureterovesical anastomotic techniques for kidney transplantation: a systematic review and meta-analysis

No consensus exists about which ureterovesical anastomosis technique to use for kidney transplantation. The aim of this systematic review was to compare the existing techniques in relation to the risk of urological complications. All studies that compared ureterovesical anastomotic techniques in kidney transplantation were included. Study endpoints were urinary leakage, ureteral stricture, vesicoureteral reflux and hematuria. Subanalyses of stented and nonstented techniques were performed. Two randomized clinical trials and 24 observational studies were included. Meta-analyses were performed on the Lich-Gregoir (LG) versus Politano-Leadbetter (PL) techniques and LG versus U-stitch (U) techniques. Compared with the PL technique, the LG technique had a significantly lower prevalence of urinary leakage (risk ratio (RR): 0.47, 95% confidence interval (CI): 0.30 to 0.75) and a significantly lower prevalence of hematuria when compared with both PL and U techniques (RR: 0.28, 95% CI: 0.16 to 0.49 and RR: 0.23, 95% CI: 0.11 to 0.50, respectively), regardless of ureteral stenting. There was no difference in the prevalence of ureteral strictures or vesicoureteral reflux between the various techniques. Of the three most frequently used ureterovesical anastomotic techniques, the LG technique results in fewer urological complications than the PL and U techniques.

Removal of foley catheters in live donor kidney transplant recipients on postoperative day 1 does not increase the incidence of urine leaks

Catheterization of the urinary bladder during kidney transplantation is essential. The optimal time to remove the Foley catheter postoperatively is not universally defined. It is our practice to remove the Foley catheter on postoperative day 1 in live donor kidney transplant recipients who meet our standardized protocol criteria. We believe that early removal of Foley catheters increases patient comfort and mobility, decreases the risk of catheter associated urinary tract infections, and allows for decreased hospital length of stay. The hypothetical risk of early removal of Foley catheters would be the increased risk of urine leak. We reviewed 120 consecutive live donor kidney transplant recipients and found that there was not an increased incidence of urine leaks in patients whose Foley catheters were removed on postoperative day 1.